Ineffective communication and transfer of patient information has been associated with medical errors, patient harm and patient dissatisfaction. The Joint Commission Center for Transforming Healthcare estimates that “80 percent of serious medical errors involve miscommunication between caregivers when patients are transferred or handed-off” (2013). These errors and adverse events can result in hospital readmissions and poor continuity of care.

There are a number of influences pushing physicians and hospitals to pay closer attention to this stage of patient care, including both the Affordable Care Act (ACA) and industry trends, such as Accountable Care Organizations (ACOs). In fact, the ACA penalizes hospitals for certain readmissions within specific timeframes, providing incentive for better communication and coordination across healthcare settings. The resulting need is for greater collaboration between a variety of providers, such as hospitals, skilled nursing facilities, home healthcare workers and hospice agencies.

PSQH details one of these efforts out of Albany Medical Center (AMC), New York State’s busiest trauma center. That hospital’s readmissions reduction program partnered with several community providers to improve management of “clinically complex, high-risk patients.” The Albany Care Transitions Coalition (ACTC), as the partnership became known, analyzed data to determine causes for readmission, coached discharge nurses to call high-risk patients and “discuss appointments, medication adherence and follow-up physician care” and created “safety-net support” for some patient populations.

While some readmissions are inevitable, the work of the coalition in New York’s Capital Region shows that many improvements are not only possible but also within physician and hospital control. The ACTC was able to put into place more aggressive protocols, improve forms/reporting and expand electronic health record capacities. Ultimately, however, it credits the collaborative environment itself with making the most remarkable difference:

In this new “coalition environment,” the ACTC has been able to develop cross-setting relationships and implement standardized tools and systems that improve the transfer of information between settings and coordination of care. In addition to improving relationships among care settings, coalition meetings also improve safety and quality (Pearson, 2013).

The article is available in the May/June 2015 edition of PSQH both in print and online.